5. #ifad2019 the role of the glycocalyx (chappell)
A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects. Many questions remain to be answered indeed: Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost? Does HES still have a place in the OR? Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin? Is it really impossible to avoid fluid overload by using only crystalloids? Is there still a definitive place for human albumin? How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others? How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy? What with the fluids beyond resuscitation? And what do the authors of the big fluid trials do in real life themselves? The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill. Date: October 26th 2019, 8:00 - 18:00
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5. #ifad2019 the role of the glycocalyx (chappell)
- 1. Daniel Chappell Department of Anesthesiology University Hospital Munich The role of the endothelium in edema formation
- 3. interstitial intervasal interstitial 3 litres Na+ K+ proteinprotein water 12 litres
- 4. The Starling Principle Starling E. J Physiol 1896 Jv / A = Lp ((Piv – Pt) – σ (πiv – πt)) Ernest Starling 1866 - 1927
- 5. Vascular lumen Interstitial space hydrostatic pressure high oncotic pressure low low high The Starling Principle
- 6. hydrostatic pressure high oncotic pressure low low high Vascular lumen Interstitial space The Starling Principle
- 7. hydrostatic pressure high oncotic pressure low low high Vascular lumen Interstitial space The Starling Principle
- 8. Contradiction 1: The interstitial oncotic pressure is irrelevant for the vascular barrier competence Adamson RH et al. J Physiol 2004; 557:889-907
- 9. Is the interstitial space really protein free?! NO!!
- 10. Contradiction 2: The interstitial space is full of proteins
- 11. „Low lymph flow paradox“ Jv / A = Lp ((Pc – Pi) – σ (πc – πi)) „Net capillary filtration rate calculated from tissue- averaged Starling forces is much greater than the tissue lymph production“ JR Levick J Physiol 2004; 557.3 p 704
- 12. Contradiction 3: Far less fluid is filtrated and resorbed than estimated.
- 13. Structure and function of the vascular barrier 2019
- 18. 1000 nm
- 19. Glycocalyx Endothelial cell Vascular lumen 100 nm Chappell D et al. Cardiovasc Res 2009;83:388-96
- 23. EndothelialSurfaceLayerEndothelialcell Flow Plasma proteins Red blood cell Bloodstream
- 24. hydrostatic pressure high oncotic pressure low low high ? Ernest Starling 1866 - 1927 The Starling Principle
- 25. hydrostatic pressure high low Ernest Starling 1866 - 1927 The Starling Principle
- 26. Пe Пt Becker, Chappell, Jacob. Basic Res Cardiol 2010
- 27. Пe Пt Пe
- 28. Пg Пe Пt Пe
- 29. vascular barrier microvascular blood flow anti inflammation vascular tone coagulation
- 33. 0,1 µm C vascular lumen endothelial cell glycocalyx 1 µm glycocalyx vascular lumen 0.1 µm
- 34. 1 µm vascular lumen Interstitial edema 0.1 µm vascular lumen glycocalyx endothelial cell 0,1 µm C vascular lumen endothelial cell glycocalyx 1 µm glycocalyx vascular lumen 0.1 µm
- 37. Glycocalyx Endothelial cell Vascular lumen 0.1μm Glycocalyx Endothelial cell Vascular lumen 0.1μm Chappell D et al. Cardiovasc Res 2009;83:388-96
- 39. vascular barrier vascular tone anti-inflammation Oedema Inflammation/SIRS coagulation Thrombosis Fibrinolysis microvascular blood flow Ischaemia Vasoconstriction
- 40. Trauma
- 41. Increased glycocalyx shedding associated with: - Increased vasopressor need - Inflammation - Coagulopathy - Independent predictor of mortality Johansson PI et al. Ann Surg 2011;254:194-200
- 42. Sepsis
- 43. • Observational trial • Patients with severe sepsis (n=262) • High-risk ARDS, APACHE ≥25 • EG Shedding (Syn-1) and organ dysfunction
- 46. Hypervolemia
- 47. Volume effect of colloids: 90-100% Rehm M et al. Anesthesiology 2001;95:849-56 Normovolemia
- 48. Volume effect in hypervolemia: approx. 40% Normovolemia Hypervolemia Rehm M et al. Anesthesiology 2001;95:849-56
- 49. plasmavolume(ml) Rehm M et al. Anesthesiology 2001;95:849-56 PV = 2,986 ml
- 50. EndothelialSurfaceLayerEndothelialcell Flow Plasma proteins Red blood cell Bloodstream
- 51. plasmavolume(ml) Rehm M et al. Anesthesiology 2001;95:849-56 PV = 2,986 ml + 1,400 ml isooncotic colloid
- 52. plasmavolume(ml) Rehm M et al. Anesthesiology 2001;95:849-56 PV = 2,986 ml PV = 3,580 ml
- 53. Colloidal volume-effects are context-sensitive Jacob, Chappell, Rehm. Lancet 2007, 369: 1984-6
- 54. Conclusion • Glycocalyx major part of vascular barrier • Regulates vascular health • Deteriorated by many events • Impacts outcome • Major role in volume management • Only top of iceberg known
- 55. Consider physiology! Take Home Message
- 56. Take Home Message Focus on the relevant things!
- 57. Think about the macrocirculation... Take Home Message
- 58. ...but also the microcirculation! Take Home Message 1965 2012
- 59. Thank you!